why physicians do not diagnose alzheimer’s disease mark a. sager, md professor of medicine and...

Why Physicians Do NotWhy Physicians Do NotDiagnose Alzheimer’s DiseaseDiagnose Alzheimer’s Disease

Mark A. Sager, MDMark A. Sager, MDProfessor of Medicine and Population Health Sciences

Director, Wisconsin Alzheimer’s Institute

University of Wisconsin Medical School

WISCONSIN ALZHEIMER’S INSTITUTE

Age

CognitiveFunction

248

Death

MCI

AD syndrome

Normal aging

Interventions

Diagnosing Alzheimer’s Disease

• Almost 50% of persons with dementia are never diagnosed or treated

• Most persons who are treated for dementia are treated inappropriately


Underrecognition of Cognitive Impairment in Assisted Living Facilities

• 230 ALF residents in 7 facilities in Nebraska

• Not dementia-specific

• Defined cognitive impairment as <24 on the MMSE


JAGS, 2005

Underrecognition of Cognitive Impairmentin Assisted Living Facilities


353JAGS, 2005

63%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

tag

e

MMSE < 24MMSE ≥ 24

Underrecognition of Cognitive Impairmentin Assisted Living Facilities


354JAGS, 2005

75%

22%

11%

63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

tag

e

No diagnosis No treatment Self-medicate Surrogate decision-maker

For persons with For persons with MMSE < 24 (N=145)MMSE < 24 (N=145)

Prevalence of Undetected MCI – Study Population

Mean age (yrs) 76

Female (%) 58

Education (yrs) 16

Mean MMSE 28

Source: Hermann, Sager 2002


17

Prevalence of Undetected MCI

N (%)

Undetected dementia (n = 200) 21 (11)

Undetected MCI (n = 179) 18 (10)

Rate of undetected impairment 39 (20)

Source: Hermann, Sager 2002


Interest in Screening andTreatment for MCI


• Questions from Alzheimer’s Association website “fact sheet”

• N= 149

• 71% over age 65

Dale et al JAGS, 2006


Would you want to be tested for memory problems as part of a routine medical exam?

Yes 80 %




Would you want to know as early as possible that you had Alzheimer’s Disease?

Yes 92%



Interest in Screening and Treatmentfor MCI - Conclusion


“Older adults expressed high interest in screening and treatment for MCI. Such high interest is potentially troubling…”


Reasons for High Rate ofUndiagnosed Cases of Dementia

• Reliance on family

• Subtlety of early symptoms

• Low priority given by MD’s


Why Physicians Do Not Diagnoseand Treat Alzheimer’s Disease

Deficiencies in Current Knowledge

Practice Obstacles

Uncertainties

Avoidance Behavior and Skepticism

Plus

Create

Which lead to


Potential Benefits of Treatment with AcetylCholinesterase Inhibitors

• Slow cognitive decline

• Delay emergence of behavioral symptoms

• Slow functional decline

• Reduce caregiver stress

• Delay nursing home placement


-4

-3

-2

-1

0

1

2

3

4

5

6

70 1 3 6 9 12

Galantamine 24 mgPlaceboGalantamine 24 mg

Galantamine Long-term Cognitive Function Over 12 Months

Improvement

DeteriorationMea

n C

hang

e in

AD

AS

-cog

fro

m

Bas

elin

e

Time (months) Raskind, MA, et al. Neurology 54:2261-2268; 2000.

=P<0.05

Double-blind Open-extension


58

Alteration of Clinical Outcomes in the NaturalHistory of AD by Cholinesterase Inhibitors


• University of Pittsburgh ADRC

• 270 patients with AD; 135 CEI and 135 no-CEI

• Matched for age, education, MMSE, duration of dementia

Lopez, et al., JAGS, 2005


• Average mean change in MMSE/yr was 3.8 points ± 4.2 for 1,139 AD patients in ADRC

• Classified study patients as slow progressors (≤ 2 change in MMSE/yr and rapid progressors (≥ 3 change in MMSE/yr)

• Mean age 73, mean MMSE 19, mean education 12.5 years

Lopez, et al., JAGS, 2005

Alteration of Clinical Outcomes in the NaturalHistory of AD by Cholinesterase Inhibitors

Effect of CEI Treatment on AD Progression


0%10%20%30%40%50%60%70%80%90%

100%

Treated Not Treated

Pe

rce

nta

ge

Slow ProgressionRapid Progression

RR=2.45 (1.45-4.16), p=.001

Lopez et al., 2005

N=81 N=82

N=54 N=53

60%

40% 39%

61%

Effect of CEI Treatment on Risk of Nursing Home Placement


Lopez et al., 2005

0%10%20%30%40%50%

60%70%80%90%

100%

After 2 yrs After 3 yrs

Pe

rce

nta

ge

TreatmentNo Treatment

1% 11% 11%

50%

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 100 200 300 400 500 600 700 800 900

Probability of Remaining at HomeP

rob

abil

ity

of

Rem

ain

ing

at

Ho

me

Time (Days)

Tacrine Dose (mg/day)

< 80

> 80 < 120

> 120 < 160


Knopman D, et al. Neurology 47:166-167; 1996

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 100 200 300 400 500 600 700 800 900

Probability of SurvivalP

rob

abili

ty o

f S

urv

iva

l

Time (Days)

Tacrine Dose (mg/day)

< 80

> 80 < 120

> 120 < 160


91Knopman D, et al. Neurology 47:166-167; 1996


Caregiver Interventions to Reduce NursingHome Placement of Patients with AD

• RCT of 406 caregiver spouses, 1987-1997

• New York University

• Required treatment group to attend support groups (58%)

• Allowed control group to attend support groups (42%)

Neurology, 2006



Intervention

• Counseling sessions – family (4), individual (2)

• Resource and referral information, behavioral management, telephone help

• Weekly support groups

Neurology, 2006



Results - summary

• Median delay in NHP = 557 days (1.5 years)

• Effects of intervention on NHP due to improvements in caregivers well being (tolerance, depression, satisfaction with support)

• Potential savings of $90,000/patient for 1.5 year delay

Neurology, 2006


2004 Medicaid Costs for WisconsinNH Residents with Dementia

10,140 persons at $117 per day $455,235,120

State / County Share (40%) $182,094,120

( In 2004, 1600 persons with dementia were served in COP,COP-W and CIP at a cost of $16.7 million)

Potential Long Term Care Savings ofTreating Alzheimer’s Disease in Wisconsin


• $4.1 million Medicaid savings for delaying NH entry by 1 year for 100 persons

• $5.7 million personal savings for delaying NH entry by 1 year for 100 persons

Source: J Alz Assoc, 2006

Disease Modifying Drugs in Development


• Tramiprosate (Azhmed) – reduces deposition of Beta amyloid

• Beta secretase inhibitor

– reduced rate of ADL loss by 48%

– reduced rate of cognitive loss by 34%

MMSE – Diagnostic Accuracy

Abnormal (< 24)

%

Normal (≥ 24)

%

Normal 0 100

AD 60 40

Vascular 52 48

Mixed 71 29

Lewy Body 71 29

Frontal Lobe 31 69

Sensitivity – 47

Specificity - 100


Clock Draw – Diagnostic Accuracy

Abnormal (≤ 8)

%

Normal (> 8)

%

Normal 26 74

AD 87 13

Vascular 82 18

Mixed 86 14

Lewy Body 95 5

Frontal Lobe 71 29

Sensitivity – 77

Specificity - 74


Animal Fluency – Diagnostic Accuracy

Sensitivity – 90

Specificity - 76

Abnormal (< 17)

%

Normal (> 17)

%

Normal 24 76

AD 91 9

Vascular 90 10

Mixed 100 0

Lewy Body 100 0

Frontal Lobe 100 0


Wisconsin Dementia Research Consortium Study


Animal Naming

Diagnostic group Abnormal (< 14) Normal (≥ 14)

Normal Cognition 12% 88%

AD 85% 15%

Other dementia 85% 15%

Animal Naming


Introduction: “I’d like to ask a question to check your memory.”

Instruction: “Tell me the names of as many animals as you can think of, as quickly as possible.”

Procedure: Time for 60 seconds and record all responses.

If the person stops before 60 seconds, say “Any more animals?”

If the person says nothing for 15 seconds, say “A dog is an animal.Can you tell me more animals?”

1. _______________________ 12. _______________________2. _______________________ 13. _______________________3. _______________________ 14. _______________________4. _______________________ 15. _______________________5. _______________________ 16. _______________________6. _______________________ 17. _______________________7. _______________________ 18. _______________________8. _______________________ 19. _______________________9. _______________________ 20. _______________________10. _______________________ 21. _______________________11. _______________________ 22. _______________________

Scoring: Count the total number of animals (NOT including repetitions or non-animal words): ______________________

dogcatcowpigsheephorseliontigercatmouseant

spraydandelionbird


LOC ORI ATT LANGUAGE CONST MEM CALC REASONING

COMP REP NAM SIM JUD

†AVG. RANGE -ALERT- --12--

--10--

-(S)7-

--6--

-(S)6-

--5--

--(S)--

--12--

--11--

--(S)--

--8--

--7--

--6--

-(S)5-

--4--

--12--

--10--

-(S)4-

--3

--8--

-(S)6-

--5--

--6--

-(S)5-

--4--

MILD

MODERATE

SEVERE

--IMP--

--8--

--6--

--4--

--5--

--3--

--1--

--4--

--3--

--2--

--9--

--7--

--5--

--5--

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--2--

--3--

--2--

--0--

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--1--

--0--

--4--

--3--

--2--

--3--

--2--

--1--

Write in lower scores

12 7 6 12 8 5 10 4 7 5

COGNITIVE STATUS PROFILE

WAINDZ

Screening Study Data Summary





--10--

-(S)7-

--6--

-(S)6-

--5--

--(S)--

--12--

--11--

--(S)--

--8--

--7--

--6--

-(S)5-

--4--

--12--

--10--

-(S)4-

--3

--8--

-(S)6-

--5--

--6--

-(S)5-

--4--

MILD

MODERATE

SEVERE

--IMP--

--8--

--6--

--4--

--5--

--3--

--1--

--4--

--3--

--2--

--9--

--7--

--5--

--5--

--3--

--2--

--3--

--2--

--0--

--8--

--6--

--4--

--2--

--1--

--0--

--4--

--3--

--2--

--3--

--2--

--1--


12 7 6 12 8 5 10 4 7 5


WAIMCIZ






--10--

-(S)7-

--6--

-(S)6-

--5--

--(S)--

--12--

--11--

--(S)--

--8--

--7--

--6--

-(S)5-

--4--

--12--

--10--

-(S)4-

--3

--8--

-(S)6-

--5--

--6--

-(S)5-

--4--

MILD

MODERATE

SEVERE

--IMP--

--8--

--6--

--4--

--5--

--3--

--1--

--4--

--3--

--2--

--9--

--7--

--5--

--5--

--3--

--2--

--3--

--2--

--0--

--8--

--6--

--4--

--2--

--1--

--0--

--4--

--3--

--2--

--3--

--2--

--1--


12 7 6 12 8 5 10 4 7 5


WAISDATZ



Animal Naming screen

Adults > 65 years

Diagnose and Treat Refer to Dementia Diagnostic Clinic

Re-Screen at Intervals

–

Cognistat

+

Referral to MD

_

+

Memory Screening Process

County Services and/or Alzheimer’s Association

County Services and/or Alzheimer’s Association

Cognitive Screening Results – 8 Wisconsin Counties


Persons approached 1244

Persons screened 1120 (90%)

Persons screened positive 370 (33%) (range 22%-58%)

Abnormal Cognistat 92%

Undertreatment of Alzheimer’s Disease


• Only 35% of persons with AD have ever been prescribed one of the standard treatments.

Source: J Alz Assoc, 2006

why physicians do not diagnose alzheimer’s disease mark a. sager, md professor of medicine and...

Documents

undetected dementia

undetected mci n

mean mmse

ad patients

screening andtreatment

alzheimers diseasedeficiencies

naturalhistory of ad

mean education